Quality Account 2015-2016
Our Vision is that “Everyone has choice and excellence on their journey towards the end
of life”
Our Mission statement:
Keech Hospice Care exists to provide high- quality accessible specialist palliative care (SPC); and work in partnership to influence
and educate others in End of Life Care
Table of Contents
Part 1: Report from the Chief Executive Officer and Clinical Director ...... 4 Objectives...... 6 Part 2: Priorities for improvement...... 11 2a. Priorities for improvement in 2016 – 2017 (Adults and Children’s) ...... 11 2b. Progress against Priorities for Improvement in 2015 – 2016 ...... 13 Part 3: Statements of assurance from the Board ...... 16 3a. Review of our services ...... 16 3b. Participation in Clinical Audit ...... 19 3c. Research ...... 20 3d. Use of CQUIN payment framework ...... 20 3e. Statement on the Care Quality Commission ...... 20 3f. Data Quality ...... 21 3g. Information Governance Toolkit ...... 21 3h. Clinical coding error rate ...... 21 3i. Organisational Meeting Structure ...... 22 Part 4: Review of Quality and Safety Performance...... 24 4a. Internal Audit Activity 2015/16 ...... 24 4b. Trustee Visits ...... 28 4c. Patient Led Assessment of the Care Environment (PLACE) ...... 28 4d. Workplace Inspections ...... 29 4e. Benchmarking ...... 30 4f. Keech Hospice Care summary clinical governance overview (April 2015 – March 2016) ...... 31 4g. What people say about us…… ...... 34 Section 5: Feedback from our NHS Commissioners ...... 35
Part 1: Report from the Chief Executive Officer and Clinical Director
Together with the Board of Trustees, I would like to thank all our staff and volunteers for their achievements over the past year. Despite the current economic climate, the Hospice has continued to support people in need of our services whilst remaining financially sound.
In February 2016 I commenced post at the Chief Executive having previously been the Clinical Director. We also have a new Chair of Trustees, Clive Medlam, and the wider experience of our board continues to serve us well.
At Keech Hospice we strive to continually deliver safe and innovative services, whilst giving reassurance that the organisation as a whole has patient care and quality at its core. The safety, experience and outcomes for all our patients and those close to them are of paramount importance to us. We always try to reflect the needs of our diverse community and we are proud to be caring for 18% of adults and 31% of children from BME groups. We have also expanded our care to non-cancer patients who now form 36% of our adult patients.
In the last year we have provided 175 adults and children with 2206 in-patient bed nights; we have undertaken 1269 community visits to children’s service patients; 234 adult patients have attended our Palliative Care Centre 2015 times; 1028 adult patients have been supported by our ‘My Care Co-ordination Service ‘.
We are working on a tailor made development plan to help us to ensure our management and governance arrangements are robust.
I am responsible for the preparation of this report and its contents. To the best of my knowledge, the information reported in this Quality Account is accurate and a fair representation of the quality of healthcare services provided by our Hospice.
Liz Searle Chief Executive Officer
4 Keech Hospice Care Quality Account 2015/16
Report from the Clinical Director
Keech hospice care continues to provide high quality specialist palliative care to adults and children with progressive life limiting illness. We provide this to adults in Luton and south Bedfordshire and children in Bedfordshire, Hertfordshire and Milton Keynes. We have two in- patient units, community services and outpatient services.
It is important to us that we always continue to look ahead and work with colleagues and service users to identify gaps and find innovative ways to fill them.
During 2015-16 we have worked in partnership with Macmillan cancer support to develop an independence and wellbeing service to support adults from the beginning of their time living with a life limiting illness.
We have also identified the need to provide support to bereaved people in Luton who may not have had a family member die with us but require bereavement support. Talking Elephants is a successful community support group and next year we hope to build on this.
In children's service we have recognised the need for a co-ordinated approach by professionals to children's care and in Luton have lead on setting up and developing multi-disciplinary meeting to discuss caseloads and plan care. We have also worked with other professionals to develop an information leaflet for parents when their child dies. This will mean that wherever in Luton a child dies the information the parents receive will be the same. We plan to work with professionals in the other areas we cover to do the same. Our staff work with other health and education providers to ensure our young people have a special education plan.
Elaine Tolliday Clinical Director
5 Keech Hospice Care Quality Account 2015/16
Objectives Achievements and highlights from 2015/16 were monitored against our strategic objectives:
Objective 1 – Delivering Excellent Care
Palliative Rehabilitation Service: An occupational therapist was appointed to Keech in December 2015 after a scoping exercise identified that a Palliative Rehabilitation service would benefit patients with a palliative diagnosis. The Macmillan funded service is to include a physiotherapist and an occupational therapist working with other allied health professional posts in hospital and community services.
This quarter, services and models of practice for target patients have been fully researched, using information from other hospices with established rehabilitation services. These services are focused on improved physical function, self-management and health and wellbeing, which enhances knowledge, independence and self-care.
The occupational therapist works 3 days weekly and the physiotherapist position, for the same hours, continues to be advertised.
Objectives are as follows: To develop opportunities for carers and families to enhance psychological resilience. To maximize access to services across Luton and South Beds so that all patients with a palliative diagnosis are introduced to a flexible programme, offering therapeutic services at the right time in their pathway. To raise awareness of the specific services available to patients with a palliative diagnosis, their carers and families, across the hospital, community and hospice. Research has so far concentrated on understanding the current service provision for people with palliative conditions in the Luton and South Beds area, which has involved liaising with key staff. Referral processes are amongst the areas being examined with the palliative rehabilitation steering group.
Initial groups planned: Fatigue Management Group- In partnership with Sybs Almassy (KPCC), a 6 week programme will be starting in June 2016. Walk and Well-being Group-Teaming up with staff from Active Luton, this 8 week programme is expected to start in the summer.
6 Keech Hospice Care Quality Account 2015/16
Non Malignant MDT’s (Heart Failure, Rare Neurological, Respiratory): These are now well established and are proving to be proving to be successful in providing a forum centred on patients’/families’ care and future planning. They are used as an educational platform for staff to learn from each other’s experience. All three of the MDT’s are now consultant-led.
Palliative Care Centre: Our Palliative Care Centre continues to offer planned holistic palliative care to our patients and their families. An outpatient service is offered to those patients with malignant and non-malignant illnesses who are deemed to be within the last 2 years of their life.
My Care Co-ordination service: The team continue to promote the service locally. The team regularly attend rare neurological, heart failure and respiratory multi-disciplinary meetings, representing the support we can offer patients to help them to remain at home. In the last year they have introduced follow up calls for all patients and a call back service to offer regular support, this is helping to introduce patients to our service. We hope that this could help to reduce hospital admissions further by detecting issues earlier.
Adult In-Patient: The unit has worked under challenging staffing levels this year. We have introduced patient dependency scoring which has proved to be an accurate way of managing the in-patient beds.
Luton Paediatric MDT: continues to run on a monthly basis at the Luton & Dunstable Hospital. The MDT is attended by Health and Social Care colleagues. The MDT is jointly chaired by our Clinical Development Lead and the lead Paediatric Oncology Nurse at the Luton & Dunstable Hospital.
Luton Strategic Palliative Care Network: We have been a part of this group which has now finished a piece of work to locally roll out a leaflet for parents to use when a child dies. The booklet is entitled “What to do next” and is now available for parents at Keech.
Advance Care Plans in Children’s Service: The Children’s Service are working on the use of Advance Care Plans for children and young people. The East of England Strategic Network has agreed to adopt the West Midlands toolkit, and the Clinical Development Lead will be leading on this project at Keech over the coming months.
Children’s In-patient Unit – Following extensive building works in 2014/15 which was funded by a Department of Health capital grant, we have now been able to start work on our garden/courtyard which has been designed by our families and the team. This was funded by a local benefactor.
Children’s Community service: The team continue to provide care to children and their families at home, school and in hospital. 7 Keech Hospice Care Quality Account 2015/16
Children’s Day Support: This remains an area of development with services being offered in-house and in the community. Admission to this service is based on the assessed need of the individual child and family. Two new services have been introduced within Day Therapy, they are the Parent Support Group which meets monthly and is facilitated by Keech staff, the other is a Specialist Palliative Care Clinic which runs weekly and is facilitated by a Doctor and a Senior Nurse.
Supportive Care: This year has seen the introduction of an outreach post-bereavement drop-in group for all post-bereaved people within the local community, the group meets monthly and attendance so far has been very good.
In March the Art Therapist facilitated a study day at Keech in partnership with Creative Response (special interest group for art therapists working within palliative care, aids, cancer and loss). The theme was ‘Secondary Trauma’ that clinicians may experience from working within this field. The day consisted of a speaker on this topic, followed by reflective art making and a discussion. The day was attended by a number of art therapists and students and was very successful.
This year we have slightly changed our approach, with the Children’s Service Art Therapist being more visible and available for informal sessions on the children’s unit. As a team, we are ensuring that patients and carers are receiving the most appropriate support, with patients and carers now receiving more Family Support Worker and Music Therapist sessions rather than just Art Therapist sessions. The increase in talking support sessions has also been made possible due to the addition of another Family Support Worker, Natalie, to our team.
MYCAW has been identified as a popular and straightforward assessed outcome measure for complementary therapy, and it is planned that this will be piloted soon. The Music and Art Therapists have commenced piloting outcome measures SDQs (Strengths and Difficulties Questionnaire) for the Children’s Service, and COR outcome measures for the Adult Service.
Dementia Co-Production: Keech have played an active part in this project was funded by NHS East of England Strategic Clinical Network for Mental Health, Neurological Conditions, Learning Disability and Autism (SCN) and the National Development Team for inclusion (NDTi). The Luton Dementia Co-Production was developed by Luton NHS Clinical Commissioning Group (CCG) in partnership with; unpaid carers (of people living with dementia), Age Concern Luton, Alzheimer’s Society, Cambridge Community Services, East London Foundation Trust, GP representation, Keech Hospice Care, and Luton Borough Council.
The Aims of the project were: to develop and understand the process of co-production, by establishing and reviewing co-production as a methodology for project development, with the involvement of unpaid carers of People Living With Dementia (PLWD) and professionals 8 Keech Hospice Care Quality Account 2015/16
to identify, through focus project interviews with carers, what are the main causes of stress for carers of PLWD.
Reports on the ‘process of co-production’ and the ‘carer evaluation’ are available from [email protected].
We continue to work closely with other professionals in the community to ensure we continue to offer patients a seamless service.
Objective 2 – Educate and Communicate Education for Health Care Assistants: A programme of Education for Health Care Assistants has been prepared to include a range of topics relating to palliative care. This will be delivered in May 2016.
Collaboration with the University of Bedfordshire: We have recently been working with the University of Bedfordshire to develop opportunities for joint working around research. More recently, this has been very positively received and shortly we hope to confirm a jointly funded research studentship (a 3-year Ph.D. student research programme). This is really exciting, as it marks the beginning of a long-term relationship with the university to develop a centre of innovation and excellence, under the banner of Keech. In addition to this, a Charityworks graduate trainee working at Keech is currently working with university professors to develop a research proposal on health and well-being of staff. Collaboration during the initial stages of the project will help to ensure publication standards are met.
Nurse Revalidation: We have set up workshops to enable our nurses to prepare themselves for revalidation. We have invested in a new module on our Learning Management System which will enable them to collect and record their evidence.
Objective 3 – Value for money Overall our statutory income at the end of 2015/16 stands £156k, this is an 8% increase achieved through a successful statutory funding grant (NHS England IT Capital grant), and additional statutory funding received through the NHS England Luton Dementia Co-production project, CQUIN’s, CHC funding and inflationary increases.
NHS Commissioned activity during 2014/15, especially Adult Inpatients, has remained high; however, funding from some CCGs is not reflecting the activity or complexity of care provided. We therefore continue to raise this issue with commissioners formally at our quarterly contract review meetings.
9 Keech Hospice Care Quality Account 2015/16
Objective 4 – To be Well Governed We have a new Chief Executive, Liz Searle who was appointed in January 2016. Liz has been employed with us since 2012 in her previous role of Clinical Director. Liz’s weekly blogs have proved popular with staff and volunteers.
Our senior and operational managers took part in a development day in January from which there are further plans of work. We want to be efficient and effective and to spend as much money as possible on our purpose (caring for people) and avoid any waste of resources. We have started to look at the possibility of a programme of work which helps us work smarter. There is a focus on continual improvement to ensure that as we grow, we remain efficient and effective. We will be mapping our processes (including patient journeys) to ensure they are safe, effective, caring and responsive.
Leadership training in the ‘9 Conversations of Leadership’ started in January 2016.
Our strategic themes from 2015/16 are:
1. To deliver excellent palliative care. 2. To educate, communicate and influence others to deliver excellent palliative care by sharing our experience and expertise. To educate the public about death and dying. 3. To be well funded so we maximise organisational impact 4. To be well governed and led 5. To maximise our people resource (staff and volunteers) 6. To use business intelligence to further our aims
10 Keech Hospice Care Quality Account 2015/16
Part 2: Priorities for improvement
The Board of Trustees is committed to the delivery of high quality care that is safe, effective and provides patients and carers with a positive experience.
2a. Priorities for improvement in 2016 – 2017 (Adults and Children’s) To Deliver Excellent Care: Priority 1: To provide more outreach services in the community
Target: To have one children’s outreach support group and two well-being groups for adults
How was this identified as a priority? Needs identified through the work we do with our ‘My Care Co-ordination’ team and discussions with other care providers. How will this priority be achieved? Children’s outreach support – will be set up in consultation with service users and healthcare professionals Well-being and independence groups will be set up in partnership with Active Luton How will progress be monitored? Through regular updates and reports to our Clinical Managers Group, Senior Management Team and to the Board of Trustees
Priority 2: To further promote ‘My Care Co-ordination’ service to other healthcare professionals
Target: To increase the number of referrals to the service and maximise the ‘My Care’ caseload
How was this identified as a priority? This is a system wide CQUIN How will this priority be achieved? Working with the community and hospital teams to raise awareness of the service
11 Keech Hospice Care Quality Account 2015/16
How will progress be monitored? Reporting via the Quarterly Quality Report to staff, Senior Managers, Trustees and Commissioners Priority 3: To provide bereavement support to families on the ‘My Care Co-ordination’ caseload
Target: To have this service set up with a support worker in post
How was this identified as a priority? Through research carried out with current caseload How will this priority be achieved? Funding for this post has been agreed, post to be advertised and recruited
How will progress be monitored? Numbers of families supported will be reported by the Supportive Care Team via the Quarterly Quality Report
Educate & Communicate: Priority 4: Scope and develop an implementation plan for education to be delivered to external healthcare professionals
Target: To have a plan in place
How was this identified as a priority? Identified as a need through discussion with external healthcare professionals How will this priority be achieved? Keech will recruit someone to undertake a scoping exercise
How will progress be monitored? Regular progress reports to the Board via the Quarterly Quality Report
To maximise our people resource (staff and volunteers): Priority 5: Implement responsive and flexible recruitment practices to ensure we can find the best people to fill our vacancies Target: To have a reduced vacancy factor
12 Keech Hospice Care Quality Account 2015/16
How was this identified as a priority? Through issues identified in relation to staffing shortages How will this priority be achieved? Through partnership working between HR and Care to develop a recruitment plan How will progress be monitored? Vacancy factor and staff turnover will be reported to the Board of Trustees via the HR Quarterly Quality Report Priority 6: To improve staff engagement in the organisations direction
Target: To improve staff survey results and be in the ‘Top 100’ in the Times Staff Survey
How was this identified as a priority? From the results of the last survey in 2014, new CEO in place since January 2016
How will this priority be achieved? New CEO and Senior Management Team are actively working to improve staff engagement. Taking part in the Times 100 Survey in November 2016 How will progress be monitored? Through the results of the above survey
2b. Progress against Priorities for Improvement in 2015 – 2016
To Deliver Excellent Care Progress in 15/16
Priority 1: To develop Palliative Rehabilitation Services as part of our universal specialist offer to patients with long term conditions. Target: Recruit additional staff in response to a successful funding application, Occupational Therapist in post and scoping potential for physiotherapy and occupational therapy staff. services. Physiotherapist still to be recruited.
Priority 2: Enhance Supportive Care and Bereavement services as part of our universal specialist offer to family members
13 Keech Hospice Care Quality Account 2015/16
Target: Produce strategy for Supportive Care. Strategy written and agreed, Bereavement Support agreed as the priority
Increase our capacity to care for more people by expanding our services into the community so all patients and families in our Priority 3 catchment area, who want a community based service, have access to full specialist palliative care support, wherever they need it.
Target: Explore models and devise business plan for adult Hospice in the Options discussed with the commissioners, as yet no funding Home team. available.
Educate and Communicate : Progress in 15/16
Increasing the range and quantity of education, training and research opportunities through a learning hub model to deliver Priority 4 these both internally and externally; clinical and non-clinical.
Target: Scope and develop an implementation plan for a new commercial Partnership to support research agreed with University of venture for an education service for Keech. Where possible in Bedfordshire, scoping moved to 2016/17 as a priority. partnership with an academic institution.
To maximise our people resource (staff and volunteers)
To ensure we have the full Multidiscipline Team in the right numbers with the right competencies to be recognised as a Priority 5: Specialist Service
14 Keech Hospice Care Quality Account 2015/16
Target: Full MDT in place Team nearly complete, awaiting recruitment of Physiotherapist.
15 Keech Hospice Care Quality Account 2015/16
Part 3: Statements of assurance from the Board 3a. Review of our services During 2015/16 Keech Hospice Care provided the following specialist palliative care services to the NHS:
Adult Service Inpatient unit Palliative Care Centre Care Co-ordination Services Drug Therapies
Children’s Service Inpatient unit Day Support Community Nursing Team
In addition we have also provided the following services through charitable funding: Hospice at Home Complementary Therapy Music Therapy Family and Carer support Bereavement Care Spiritual Care Hydrotherapy pool
16 Keech Hospice Care Quality Account 2015/16
Adult Service (excluding co-ordination service)
Total number of beneficiaries in 2015/16 in the adult service was 629. This is made up of 417 patients and 212 relatives/family members.
Patient Demographics 80 300 70 Male Female 60 50 250 40 30 20 10 200 Numberof Patients 0 19-24 25-64 65-74 75-84 85 and over 150 non-BME Diagnosis Age Categories (years)
umberof Patients BME not N 100 recorded , Cancer 3% Diagnosis , 61% 50
0 Luton Bedford Other
non-BME 218 121 4
BME 61 11 2 Non Cancer Diagnosis, Total BME year to date = 18% (Last year 19.7%) 36%
17 Keech Hospice Care Quality Account 2015/16
Children’s Service
Total number of beneficiaries in 2015/16 in the children’s service was 423. This is made up of 267 children and 156 relatives/family members.
Patient Demographics 50 80 Male Female Non-BME 40 70 BME 30 20 60 10 Numberof Patients 50 0 0-4 5-9yrs 10- 16- 19+ 40 15yrs 18yrs yrs
30 Age Categories (years)
20 Cancer Diagnosis , 10 16%
0 Camb & Milton Herts E&N Out of Peterbor Luton Bedford Keynes Valley Herts Area ough Non-BME 2 15 12 42 47 63 2 BME 0 2 53 14 7 7 1
Total BME in 2015/16 = 31.4% Non Total BME in 2014/15 = 29% Cancer Diagnosis, 84%
18 Keech Hospice Care Quality Account 2015/16
My Care Co-ordination Service
Total number of new registrations 594 (53 of whom were already known to Keech
Deaths 463
Discharges 42
Average length of time on caseload 202 days (of those who were discharged or died)
Number of hospital avoidances 50
3b. Participation in Clinical Audit
• During 2015/16 no national clinical audits or confidential enquiries covered NHS services that Keech Hospice Care provides
• During 2015/16 Keech Hospice Care participated in no national clinical audits and no confidential enquiries of the national clinical audits and national confidential enquiries as it was not eligible to participate in. However we ensured that key audits were completed using nationally recognised excellence audit tools for hospices developed by Hospice UK.
• The national clinical audits and national confidential enquiries that Keech Hospice Care participated in during 2014/15 are as follows: N/A
• The national clinical audits and national confidential enquiries that Keech Hospice Care participated in and for which data collection was completed during 2015/16 are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry: N/A
• The reports of 0 national clinical audits were reviewed by the provider in 2015/16. This is because there were no national clinical audits relevant to the work of Keech Hospice Care.
• Keech Hospice Care was not eligible in 2014/15 to participate in any national clinical audits or national confidential enquiries 19 Keech Hospice Care Quality Account 2015/16
and therefore there is no information to submit.
• The local clinical audits that were reviewed in 2015/16 are listed further in the document.
• Keech Hospice Care submits an annual National Minimum Data Set to the National Council of Palliative Care and uses nationally approved audit tools (Hospice UK) to audit Infection Control, General Medication and Controlled Drugs.
3c. Research
The number of patients receiving NHS services provided or sub-contracted by Keech Hospice Care in 2015/16 that were recruited during that period to participate in research approved by a research ethics committee was NONE.
3d. Use of CQUIN payment framework
A proportion of Keech Hospice Care income in 2015/16 was conditional on achieving quality improvement and innovation goals as specified by our Commissioning Partners and the agreed CQUIN’s where achieved in 2015/16.
3e. Statement on the Care Quality Commission
Keech Hospice Care is required to register with the Care Quality Commission and is currently registered to carry out the regulated activities:
Treatment of disease, disorder or injury Accommodation for persons who require nursing or personal care Nursing Care Personal Care
There are no restrictions on our registration. 20 Keech Hospice Care Quality Account 2015/16
The Care Quality Commission has not taken any enforcement action against Keech Hospice Care in 2015/16.
Keech Hospice Care has not participated in any special reviews or investigations by the Care Quality Commission in 2015/16.
3f. Data Quality
Keech Hospice Care did not submit records during 2015/16 to the Secondary Users Services for inclusion in the Hospital Episodes Statistics which are included in the latest published date because it is not eligible to participate in this scheme. We do however have our own system for monitoring the quality of data.
We continue to use SystmOne, electronic patient record system, which is also used by many healthcare professionals in the community meaning that we can share information from and with other services (with given consent from the patient). SystmOne is also linked with the NHS spine which makes for an easier registration process when a patient is referred into the service, it also means that our doctors are able to access test results online.
Keech Hospice Care took part in the Palliative Funding Pilot between October 2016 – January 2016. Data was collected from the start of an episode of care (the ‘spell’), and the ‘phase of illness’ (stable, unstable, deteriorating and dying) was recorded as it changed throughout the period of care. Through this pilot we have introduced OACC set of outcome measures across our services.
3g. Information Governance Toolkit
Keech Hospice Care achieved 75% using version 13 of the Information Governance Assessment Report for 2015/16: This is well above the 66% we are expected/required to score to maintain Level 2 compliance.
3h. Clinical coding error rate Keech Hospice was not subject to the Payment by Results clinical coding Audit during 2015/16 undertaken by the audit commission.
21 Keech Hospice Care Quality Account 2015/16
3i. Organisational Meeting Structure
Keech Hospice Care – Governance and Management Structure
Board of Trustees
Audit & Risk Committee
Clinical Governance Group Senior Management Team
Education Group Risk Management and Health and Safety Operational Management Team Committee Clinical Managers Meeting Information Governance Steering Group Medical Gases Committee
Drugs and Therapeutics Committee
Infection Control Group
Moving and Handling Group Legend
Notes Audit Group – Governance Children's Service
Steering Group – Management
Joint Consultative Committee – Operational
– Consultation
Staff Forum 22 Keech Hospice Care Quality Account 2015/16
23 Keech Hospice Care Quality Account 2015/16
Part 4: Review of Quality and Safety Performance
4a. Internal Audit Activity 2015/16 During 2015/16 we have undertaken the audit activity listed in the table below, for most audits we use the approved Hospice UK Audit Tools.
The Clinical Managers meet quarterly as the ‘Clinical Audit Group’, the meeting is chaired by the Clinical Development Lead for adult services. All clinical audits are presented to the group, the group also monitors action plans which arise from recommendations made through audit and progress with the annual audit program.
Progress with our audit program is then reported quarterly to our Audit and Risk Committee which is made up of trustees, lay persons and hospice staff.
Topic Status Patient Accident Audit This was an audit of all patient accidents in 2014/15. Action taken as a result of falls: o All patients have a moving and handling risk assessment on admission, if they are assessed to be at risk of falls a falls assessment is also completed. o Additional falls mats and mattress alarms have been purchased for the adult IPU, we are monitoring their effectiveness o Internal investigations conducted in regards of the patients who sustained a fracture as a result of fall
Recommendations from this audit include: o Monitoring patient falls – checking what initial assessments were carried out on admission (i.e. a Moving and Handling Assessment only or Moving and Handling Assessment and Falls Assessment) this will help decide whether a falls risk assessment should be mandatory for all patients on admission. o Doctors to record that they have seen a patient following a fall or accident, although this is reported to be normal practice it was only recorded in 15 of the accidents reported. Status: action plan closed 24 Keech Hospice Care Quality Account 2015/16
Topic Status Complaint Audit This was an audit of all complaints received in 2014/15 (not just care).
Details of individual complaints have been presented to the Audit & Risk throughout the year via the Quality and Compliance Report.
Recommendations from this audit include a review of the complaints leaflet, staff to be reminded of the process for receiving and handling of complaints, managers to be reminded to apply risk scores to complaints received within their department. Status: action plan closed Infection Control (Adult and Children’s IPU) These audits are conducted annually using the Hospice UK audit tools.
The results from both of these audits have shown significant improvement against the previous two audits. Since the last audit infection control has been a focus area for our internal monthly and quarterly safety thermometer checks as well as the recent PLACE Assessment (Patient Led Assessment of the Care Environment) that we took part in. It should also be noted that since the last audit the children’s in-patient unit has had a major refurbishment and the bedrooms on both units have also been redecorated. The CIPU action plan remains open whilst it awaits refurbishment of public toilets situated on the unit. Status: action plan open (CIPU) (AIPU Closed)
General Medicines Audit (Adult IPU, KPCC and Children’s IPU) These audits are conducted annually using Hospice UK audit tools.
The results of this year’s audits show an overall improvement in all units, with all but 3 applicable topics scoring higher compared to the previous year.
No major non-conformities were identified. Status: action plan open
Practicing Privileges Audit This is an annual audit to review the contracts/appointments of all health care professionals not employed by the charity but who have been granted practicing privileges to ensure their relevant documents are up to date. 25 Keech Hospice Care Quality Account 2015/16
Topic Status
No major non-conformities were identified. Status: action plan closed
Notes Audit A notes audit is completed every 6 months. One took place in May 2015. Overall we scored a compliance score of 96%. The second took place in November, overall we scored a slightly lower compliance of 92%
We are required to report 2 areas of this audit to our commissioners. The scores from both audits are as follows: 1. Do all patients have a multi-disciplinary holistic assessment: 36/36 adult service patients did have an holistic assessment 32/36 children service patients did have an holistic assessment 2. Do all patients have a care plan: 36/36 adult patient records audited had a care plan; 27/30 children’s records audited had a care plan (6 were counted as N/A) Controlled Drugs Audits (Adult IPU and KPCC) A Controlled Drugs Audit is undertaken annually by the Clinical Development Lead; all three care units (Adult IPU, Palliative Care Centre, and Children’s IPU) are inspected, at the time of writing this report we await the outcome of the controlled drugs audit on the children’s service. A Hospice UK audit tool is used, which is based on statutory requirements and professional best practice.
The results from this year’s audits were good with KPCC scoring 99.2% compliance and Adult IPU scoring 94.7%.
The areas requiring improvement are: Sub-topic 2: Procurement Sub-topic 4: CD register, records and audit Sub-topic 5: Prescribing of CD’s
There was 1 Major Non-Conformity – Keech do not currently use bags that are secure or tamper evident to transport controlled drugs. Containers have now been purchased that meet this requirement and we are in the 26 Keech Hospice Care Quality Account 2015/16
Topic Status process of rolling them out across all services.
There were 6 Minor Non-Conformities on adult IPU, none in KPCC, an action plan was written up to address these. Status: action plan closed
Medical Gases Audit A Medical Gases Audit is conducted annually using a Hospice UK Audit Tool. The audit tool looks at the following areas:
Sub-topic 1: Standard Operating Procedures Sub-topic 2: Personnel Sub-topic 3: Ordering and receipt Sub-topic 4: Storage Sub-topic 5: Oxygen containers Sub-topic 6: Prescribing Sub-topic 7: Administration Sub-topic 8: Decontamination and discharge.
The overall result saw an improvement on the previous year with most of the above areas requiring some improvement.
1 Major Non-Conformity was identified in the prescribing of medical oxygen. Out of a sample of 18 patients known to have been administered oxygen therapy only 13 had a written prescription for oxygen. The likelihood of an adverse reaction is very low, however if one were to happen there could be serious consequences. Medical and nursing staff were notified of the issue and committed themselves to paying closer attention to oxygen prescriptions.
5 Minor Non-Conformities an action plan was written up to address these.
Status: action plan closed
27 Keech Hospice Care Quality Account 2015/16
Topic Status Risk Management/Assessment Audit All areas if the organisation were audited to assess compliance with the charity’s Risk Management Strategy and Policy and the Risk Assessment section of the charity’s Health and Safety Policy. The auditor interviewed staff, made observations around the hospice site and inspected documentary evidence to gather their findings.
There were no Major Non-Conformities – risk was found to be effectively managed across all areas of the charity.
There were 5 Minor Non-Conformities where improvements could be made in the promptness of responding to potential risks and keeping records up-to-date and fully informative. An action plan has been written up to address these.
Status: action plan open
4b. Trustee Visits Our Trustees take their role very seriously and are committed to a programme of four trustee visits a year. The visits last a whole day and are conducted by 2 trustees on a rotational basis, they provide an excellent opportunity for trustees to observe the day to day activity of the hospice and talk to patients, visitors, staff and volunteers about their experiences and concerns (what do we do well and not so well).
4c. Patient Led Assessment of the Care Environment (PLACE) In May 2015 we took part in our first ever PLACE assessment. PLACE was first introduced by NHS England in 2013 as a system for assessing the quality of the patient environment. Our assessments were conducted by 6 service users (patients and relatives), 2 independent assessors provided by the local Healthwatch and 4 staff members. Split into teams they assessed the following areas: Children’s IPU Adult IPU KPCC Communal Areas (dining room, reception, public toilets and corridors) 28 Keech Hospice Care Quality Account 2015/16
External Grounds Food provision
Taking into account: • cleanliness; • buildings and facilities; • food and hydration; and • privacy, dignity and wellbeing
Outcome The outcome was generally very good; when assessing the care areas the first and last question asked of the assessors was:
“How confident are you that the environment supports good care” – all responded ‘very confident for all care areas assessed.
A sample of some of the main themes that came out of the assessment: Handrails – the assessment highlighted a need for handrails in communal areas or corridors used by patients and the public, these have now been put in place All public areas to undergo further assessment in relation to dementia (including dementia friendly signage) – this work is underway, our Business Manager is a member of the Luton Dementia Co-Production group. General upkeep of the grounds – some areas of the gardens found to be unkempt, garden furniture in need of repair, this has been addressed Public toilets nearest to our public restaurant is in need of redecoration – this has now been addressed
4d. Workplace Inspections Quarterly workplace inspections continue to take place and are conducted by the Health and Safety Co-ordinator, a member of the Quality and Compliance team and a Representative of Employee Safety (ROES). The Chief Executive attends two of these inspection’s as a minimum each year, the Clinical Director conducts these checks quarterly within the care areas. Any issues observed or raised are recorded on an action plan which is regularly reviewed by the Risk Management and Health and Safety Committee.
The care team also conduct monthly safety checks in their areas.
29 Keech Hospice Care Quality Account 2015/16
4e. Benchmarking We take part in the national Hospice UK Benchmarking project. We benchmark against falls, pressure ulcers and medication incidents with similar size organisations.
We continue to submit monthly data to the NHS Safety Thermometer.
30 Keech Hospice Care Quality Account 2015/16
4f. Keech Hospice Care clinical governance overview (April 2015 – March 2016) Complaints Incidents (not medication) Accidents 2015/16 2014/15 2015/16 2014/15 Serious Incidents 1 0 2015/16 2014/15 Written 3* 5 Reported to 0 0 Verbal 0 4 Care Incidents 3 3 RIDDOR *1 child service; 2 adult service (Adults) Patient falls (Adults) 8 24 (Involving patients) Patient falls 1 2 Compliments Care Incidents 8 3 (Children) Recorded compliments = 183 (Children) Patient accidents 5 6 (Involving patients) (Adults – not falls) User Experience Annual Survey Other incidents in 51 30 Patient accidents 1 6 Adult Patients = 96% responses very satisfied care areas (not (Child – not falls) (80%) or fairly satisfied (16%)with our services involving patients)
Adult Carers = 100% responses very satisfied Medication Incidents CQC Notifications (88%) or fairly satisfied (12%) with our services
2015/16 2014/15 Deprivation of Liberty = 3 Children’s service = 93% responses very Adult IPU 31 33 Serious Incident = 1 satisfied (88%) or fairly satisfied (5%)with our services Palliative Care 8 3 Friends and Family test Centre (Adults) Adults = 100% said extremely likely (96%) or Children’s Service 26 7 likely (4%) re recommend our services
Children = 100% said extremely likely (93%) or likely (7%) re recommend our services Infection Control Pressure Ulcers Safeguarding Number of patients who developed C Diff or Acquired – avoidable (grade 2, 3 and 4) MRSA while on in-patient unit: Adults 0 Cause for concern forms raised by Keech: Children 0 Adults: 9 Children: 14 C Diff (adults) 0 C Diff (children) 0 Acquired – unavoidable (grade 2, 3 and 4) Cause for concern forms raised about Keech: MRSA (adults) 0 Adults 4 Adults: 0 Children: 0 MRSA (children) 0 Children 0
31 Keech Hospice Care Quality Account 2015/16
Accidents April 15 – March 2016 No serious injuries have been sustained by patients, staff, volunteers or visitors in the reporting period April 2015 - March 2016. However there has been an SI in April 2016 (not included in the above table but mentioned on the front page. There have been a total of 15 patient accidents in this reporting year, this is 23 less than last year (decrease of 34%) Largest decrease in reported accidents can be found in Adult IPU where reported accidents have fallen by 60%, this is mainly due to the decrease in patient falls which has been achieved by putting in place a number of safety measures including the purchase of additional fall matts, mattress alerts and chair alerts.
Medication Incidents April 15 – March 2016 Overall medication incidents are up by 22 incidents on previous year (+51%) The highest increase can be seen on the Children’s unit where there is an increase of 19 incidents over the year. This, in part can be attributed to a new medication link nurse in post who has proved to be very thorough in her checking of all aspects of medication procedure and has raised her concerns through the incident reporting procedure. The Management of Medicines Group have taken her reports very seriously and are carrying out an independent review. While the number of incidents has gone up it is important to note that they are all of low risk No patients have been harmed as a result of a medication incident
Actions taken
o Where is has been appropriate staff have received additional training in the management of medication. o All errors have been discussed with staff members involved as part of their ongoing competency programme. o All third party errors have been discussed with those involved. o A meeting has been held between Keech and external Pharmacy o 1 member of staff who made an error is receiving 1-1 coaching with her manager to help address any problems. o Investigating the possibility of having a member of staff trained and registered to witness the destruction of patients own medication. o Processes for checking and measuring stock medication in KPCC has been reviewed and changes implemented
32 Keech Hospice Care Quality Account 2015/16
Patient Experience Survey
Complaints April 15 – March 2016 The number of complaints received have reduced against the previous period. Out of the three received 1 was upheld, 1 was partly upheld and 1 was not upheld. The theme running through these complaints was around communication. In all three instances the complainants were invited to meet with us to discuss the matter in more detail (1 accepted). In response to these complaints we have established a more robust structure for communicating effectively when supporting patients in the community. We also carried out reflection sessions with staff after each complaint to share the lessons learnt and highlight ways that everyone can improve communication.
33 Keech Hospice Care Quality Account 2015/16
4g. What people say about us……
“It’s like staying with a member of the family. The care, support and love they receive is “Excellent care and staff “Every single member unconditional! Thank you! of staff I have had the and services provided (Children) throughout, as well as pleasure to have been involved with are support on discharge.” amazing from walking (Adults) into reception until you leave” (Adults)
“I feel very comfortable leaving
my child to stay for a couple of
days. The nurses have all gone out of their way to get to know my child well and reassure me that she is getting excellent care “Staff excellent, all very friendly and helpful and feel and attention there.” (Children) comfortable enough to leave my daughter.” (Children)
34 Keech Hospice Care Quality Account 2015/16
Section 5: Feedback from our NHS Commissioners
1) Milton Keynes Clinical Commissioning Group have reviewed the Quality Report and have written the following: We are pleased that Keech has continued to work alongside MKCCG to sustain and further improve the quality of their services. The content of the report is well structured, with a good balance between quantitative and qualitative data and information. The report not only focuses on where the organisation has achieved its quality goals but also acknowledges where further improvements could be made.
The report provides details on 2015/16 objective achievements. This includes the implementation of 2 new services as part of the Children’s Day Support (patent support groups and specialist palliative care clinics) which is encouraging for the ongoing benefit to patients and their families. Also detailed is the refreshed informal approach to art sessions and extension of services to now include music therapist sessions. This demonstrates a valuable and responsive extension of supportive care for children and their families.
We not the appointment of a new occupational therapist however, it is disappointing that the physiotherapist recruitment has been unsuccessful following 2015/16 improvement plans and would hope that this is successful in the coming year.
There should be positive recognition around the education and communications priorities. The partnership to support research agreed with the University of Bedford demonstrates some excellent progress which we hope will further develop the educational targets for Keech in the year ahead.
The work carried out around local audit has demonstrated some excellent progress and responsive actions. Specifically, the patient accident audit detailed beneficial actioned outcomes. It is also promising to note significant infection control improvements following the previous 2 audits in this area.
The report details a very good outcome following PLACE assessments and it is encouraging to see that improvements have already been implemented following this.
There has also been some commendable work and improvements around medication incidents. The Keech team should be applauded for their commitment to transparency and improvement driven approach.
The CCG endorses the 2016/17 priorities for improvement. The implementation of a children’s outreach service, education for external healthcare professionals and targets to improve staff survey results will all greatly contribute to ensuing that patient safety, clinical 35 Keech Hospice Care Quality Account 2015/16
effectiveness and patient experience requirements continue to be delivered at a high standard.
MKCCG can confirm, to the best of our knowledge, that the Quality Account contains accurate and transparent information in relation to the range of services provided and the quality of services that Keech provides. The information provides both positive achievements and opportunities for continuous improvement.
During 2016/17 the MKCCG looks forward to working collaboratively with Keech to continually develop quality services for the residents of Milton Keynes. Jill Wilkinson, Director of Nursing and Quality, Milton Keynes CCG
2) East and North Herts Clinical Commissioning Group has reviewed the information provided by Keech Hospice and we believe this is a true reflection of performance during 2015/16, based on the information submitted during the year as part of the on-going quality monitoring process.
During 2015/16 Keech Hospice continued to deliver high quality care to the children of Hertfordshire. The Quality Account clearly sets out achievement against the priorities for 2015/16 and demonstrates continued quality improvement.
The CCG undertook a quality assurance visit in December 2015 which provided assurance around the quality of the service delivered and patient safety. The hospice also undertakes Trustee visits and work place inspections to ensure the service delivers the highest standards of care. The Hospice has not had a CQC inspection since August 2013.
The Hospice continues to ensure the service users feedback and involvement is key in supporting all areas of service development, and service user feedback is actively sought through feedback questionnaires. The quality of service provided is evident through the positive feedback received from patients and relatives throughout the year.
The priorities set out for 2016/17 build upon 2015/16 and demonstrate a commitment to all round quality improvement. The priorities are supported and embedded into the Hospice care strategy.
During 2016/17 the CCG looks forward to building on the relationship already developed with the hospice to ensure open dialogue and continued quality improvement for the population of Hertfordshire.
Beverly Flowers, Chief Executive Officer, East and North Herts CCG
36 Keech Hospice Care Quality Account 2015/16
3) Herts Valley Clinical Commissioning Group wrote: Our Head of Quality and our Programme Lead for Children, Young People and Maternity have both reviewed the document, are happy with it and have no comments to make. Ian Michaels, Contract Manager, Herts Valley CCG
4) Bedfordshire Clinical Commissioning Group have read the report and consider it comprehensive with no surprises. Any parts of the report that raise questions have been answered in recent quality submissions, I therefore personally do not have any comment other than to thank Keech for a thorough report.
Vanda Prutton, Primary Care Quality Development Manager, Bedfordshire Clinical Commissioning Group
5) Luton Clinical Commissioning Group wrote: In line with the NHS (Quality Accounts) Regulations 2011, NHS Luton Clinical Commissioning Group have reviewed the information contained within the Quality Account to provide a comment as requested by Keech Hospice.
The account is well presented and provides an overview of the services provided.
The account appears to be a true reflection of the previous year, both with the achievements attained in 2015/16 and the progress made with the 2015/16 priorities.
We are pleased to see the focus of the 2016/17 priorities to extend training and good practice to other care providers and offer more bereavement support to families. Luton Clinical Commissioning Group look forward to supporting Keech Hospice in achieving these quality improvements within the year.
Luton Clinical Commissioning Group are pleased to see Keech Hospice further developing their outreach services in partnership with other organisations and achieve a high quality service to the patients of Luton.
Colin Thompson, Accountable Officer, Luton CCG
37 Keech Hospice Care Quality Account 2015/16
38 Keech Hospice Care Quality Account 2015/16